PFI2013-00022 City of Tigard • COMMUNITY DEVELOPMENT DEPARTMENT V ® 1
Request Permit Action 7/s/3 �
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.718.2439 • www.ti arm ov
TO: CITY OF TIGARD
Building Division Services Supervisor
13125 SW Hall Blvd.,Tigard,OR 97223
Phone: 503.718.2430 Fax: 503.598.1960 www.tigard-or.gov
FROM: ❑ Owner ❑ Applicant ❑ Contractor City Staff
(check one)
REFUND OR Name:
INVOICE TO: (Business or Individual)
Mailing Address:
City/State/Zip:
Phone No.:
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
19 CANCEL/VOID PERMIT APPLICATION.
REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTOR ON PERMIT (do not cancel permit).
Permit#: ^D® 0-2--Z—
Site
z'z__Site Address or Parcel#: (, B Gyc-J 8 4r- A-z-1 y.
Project Name:
Subdivision Name: Lot#:
EXPLANATION: (1JaTL_1 A-P_C','�- N 0 T au-)
Signature: Date: /_-� m 3
Print Name: f,TfiL
Refund Policv
1. The Director or Building Official may authorize the refund of:
a) any fee which was erroneously paid or collected.
b) not more than 80%of the land use application fee when an application is withdrawn or canceled before any review effort has been expended.
c) not more than 80%of the land use application fee for issued permits.
d) not more than 80%of the building plan review fee when an application is canceled before any plan review effort has been expended.
e) not more than 80%of the building permit fee for issued permits prior to any inspection requests.
2. Refunds will be returned to the original Payer in the same method in which payment was received. Please allow 2-4 weeks for processing refunds.
FOR OFFICE USE ONLY
Rte to Sys Admin: Date By Rte to Bldg Admin: Date ZS B
Refund Processed: Date Alf,* B Invoice Processed: Date B
Permit Canceled: DateZ$' /,3 B Parcel Tag Added: Date B17
Receipt# Date Method Amount$
I:\Building\Forms\RegPemvtAction.doc Rev 05/25/2012
Jun. 14. 2013 8:59AM Apollo Drain No. 6200 P. 2
RECEIVED
JUN 17 2013
,, City of Tigard CITYOFMGMM
. s
Public FacilityIm' rovement FI Permit
I Minn,
General Information: FOR STAFF U
Property Address/Location(s):11000 1FW 130-'1 ,��� EngineeringFf 12-0 13_CD022
Case No.:
Receipt No.a
Date: tP 1'1 12D 1
*Applicant's Name: Application Accepted By:�
Address: Zz Z)a k,Revised VIAO
City/State: Zip:
Primary
Contac
. REQUIRED SUBMITTAL.
� �•, f INFORMATION
Phone: �j vl
Professional Engineered Plans are required
Contractor's Name:
CCB Expiration: j t Widening
r r '1 SubMvision Infrastructure
Address: a Main utility line extension:
1 0 Storm Drain,Sanitary—Tigard
City/State: ip:
0 Water—Tigard Water Service Area
l e f l
Phone: 0 CU (includes Durham,King Ci� and a
portion of unincorporated Washington
r County)
I
4
Plans By: I I L,
**Note:See Engineered Plan
Address: Submittal Checklist attached.
City/State: 1 t tzip:, ( , For all other work:Submit scaled sketch of the
Phone: i I ( 1 work to be done.(see attached minimum sketcb
�C?1 requirements and provided sketch area).
D ription of work I;cucpin\rmsoer\lord use appncauon\phi app.docx
tD G
Estimated value of work(within the public tight-of-way); $ `r
Is work related to a LAND-USE DECISIONP 'YES ❑ NO�K
If so,please specify(MLI',MR,SUB,etc.)case#;
Is the work related to a BUILDING PERMIT? YES❑ NO'' R
If so,please specify(BUILDING PERMIT)case#: Y
'NOTE:Person specified as"Applicant"shall be designated"Permittee"and shall provide financial assurance for the work.
City o1 Tigard I 13125 SW Hall13lvd.,Tigard,OR 97223 1 503-718-2464 1 www.tigaid-or.gov I .Page 1 of 4
Jun. 14. 2013 8:59AM Apollo Drain— No. 6200 P. 3
SKETCH AREA:
a
4 Igt9o0sw�ith
1 �x7stchc�
ll privcw u.�.�
�ropo;ec�SlWf V .
'�- ape✓{�li�,a
1
�akhoCU6
1 rJ
Cityof Tigard 1 13125 SW Nall Blvd.,Tigard,OR 97223 1 503-718-2464 1 www.dgard-or.gov ( Page 4 o f 4